22115 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building iylreO 1 \� Cir- ` .22115
net. .. SI'a- A
ams. - I CITY OF CUPERTINO-BUILDING DIVISION fp^I �Q1
Lt.Na: APPLICATION I PERMIT D —1
f c�` n`T BUILDING-ELEICTRICALPLIJMRINC-MECHAMCAL CATEGORY CONTROL N
Architect/En r. Llc No:.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT
MT--
MrCFT—
Addre.s:l n I !t'�' . . PERMITISSUANCE ❑ ❑ X7.1
LICENSED CONTRACTOR'S DECLARATION, I-�f
I hereby dorm that l am lcensed under provisions of Chapter 9(commenc. APPLIANCTSRFSIDENTIM, JOB DESCRIPTION
Ingwlth l c1on 9000)of Dl effect afthe Buslnevand PmlevlonsCodeend my
license b In f d d(ttt. PANELS
LIce C�Contr IRLr \�
Date GHITTCt 201IODO AMT'S '
ARCHITECT'S DECLARA� N �( A� '
OZ Iundentana my pbrealut be used vpubecrecoNa OVER 1000 AMI' FL S/e.Q.Fi.
COC
Cj LlcensN Professional ' SIGNS ELECTRICAL
6 w OWNER-BUILDER NLDER DECLARATION (�(I P Q T
1n]3 51'ELIALGI2CNT/MISC - 'V
71..,U,i owing affirm(that l am 31.5,Business fmmthe d Professio Llnnz AnyLaw for the
tollowing reason.(Section 70115, and and Professions Code:Any city or
TEMP.METER OR POLE INST.
'
ceuntywure,requltesapeuNltocovWui esthemprovent fors such
g an a signed
pricrer tostatement
its that
he I,abensed pursuant to the provochpermit a POWER DEVICES E ,
E+"� 6 file a signed statement that he b licensed pursuant to the pmvlslom of the
O� Contractor'sLicenee Law(Chapter I(comencingwithSectonWo
l700fDivl-
mSWIMMING POOL ELECTRIC
III---30 the basis for
Business and Professions Anyvirlation f exempt therefrom and VALUATION
6 the basis forthe rmit sulegedbjects
exemption. Anyviolation of Section7031.5 byo.mre any OUTLETSSWITCHESHXTURES
applicant fora permit subjects the applicant to a dull penalty do.more than
five hundred dolls.(&5001. NEW RESIDENTIAL ELECTR
.. ❑Las owner of the property,or my employees with wages as their sole caQ.FT' STORIES TYPE CONSTRUCTION
t compensation,w0ldothe work andthe structure Isnot Intended or offered for •,
'5 9 as sale(Sec.70K Business and Professions Code:The Contractors Limme Law _
♦;1j $ does not apply to an owner of property who builds or Improves l hereon,and OCC.CROUP RES UMTS
CC whodecs such work himself or through Ms own employees,provided that such
Improvements are not Intended oroffered for sale.ILhowerver,thebuildingor TOTAL: i
Improvement is aold within one year ofeempletlon,the owner-builderwlll have -
ttwrpudenofproving that he,did not beildmlmpormfor purpose ofsale.). QTY. PLUMBING PERMIT FEE
"L as owner of the property, FIAOD 7�h'E APN
p perry, Se exclusively contracting with tensed / PERMIT ISSUANCE
The
contractors co Liven the project(Sec.70K apply
Business and Iof fossimtsproperty
Code:
The Contractor's imp's es then law aces not apply to an owner of Property who ALTER-DRAIN A VENT-WATER�
Wilda or Improves thereon,and who mnmtts for such pkojecta with a FEE SUMMARY
cg0tit ..,exempt
under
to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am,exemp under Sec. B&P C for this reason
OUTSIDE 1:1 rS
Owner Date DRAINS FLOOR ROOF,AREA,GOND. _ SANITARY Y_ N_
T N
I
WORKMANCOMPENSATIONDECLARATION RFAQ N
❑I hereby affirm that I have a certificate of consent to selfdnsure,or aMTURESPER IRN' SCHOOL TA% Y N_
certificate of Worken'Comv
peatlon Iruu.nce ora cenifled copy thereof(Sec. RECQPI'N
380 I,Lab C. GAS -1 FA. INCAOUTLETS PARK FEE Y_ N'_
Golicy N RECEIPT N
GAS FA.SYSTEM-OVER 4(EAT BUILDING DIVISION FEES
Com env
QFAl ea copy is hereby fumiahed. CREASE/INDUS-11111,WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy V filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200Fr Date Rewi tit
(Thlaxctlon need
COMPENSATION
Isfor one hundred dollars
($l00)or less.) WATER IiFATFR W/VENT/ELECTR ENERGY FEE Y_ N
I mrtlfy that In the performance of thewwk forwhich this permit Is Issued, -
I shall not employ any person in any manner ro v to become subject to the WATIRSYSTEM/TREATING
Worken'Compemationlawsof CallfomU.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Dale Recei
Z O h'OUCETOAPPLICA -.1f,aNermakingthb Cengt.teot Exemptbn,you
should become subject to the Workers''Compeuation provisions of the Labor T _
N Code,you most forthwith comply with such provisions or this permit shall be BUIL D
seemed revoked.
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE `
a O I hembyaf6rmthat there Isaccnstmdion lendingagenry for the perform TOTAL: ELECTRIC FEE L
M Z ..on of the work for which this permit is mated(Sex.3097,CIv.C.) --
Q0 Iendre.Name - PLUMBING FEE
LL F lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certify that l have read thisapplleationand natethatthe above Information
W isconect.I agreeto complywith all city and county ordinance...deatelaws - PERMIT ISSUANCEO� FEES PAID:
r N rela0ngtobulldingrorotrucelogand herebyauthortaercpres,nlativesofthls
F dty to enter upon the above-mentioned Property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Recelptq
V against liabilities,indgnlents,costs a ed expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag told Gtyinconuxp Rfthegranting fthlsAkw �t IQ 7
Ujkol MR HANDLING uNrr(ovER)a,000cFM) CONSTRUCTION TAX
Ig a rco(Applicant/Contrador ate . E%HAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HALL RDOUSMATERI.\L DISCLOs RE
Wllltheapplicant m future building occupant store or -dl hanrdous HEATING UNIT(TO 100,000 BTU) Date Recei t(t �`�
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilea lth and Safety Cade Section 7S532(a)7 FIEATINC UNIT(OVER 100,000 BTU)' TOTAL:
E] Yes , n No
Will the a ppllcant or few m building occupant use equipment or devices VENA LATION FAN(SINGLE BESOT ISSUANCE DATE
which emit haeardous air contamiw nv as deflned by the Bay Area Air � �®
y
Quality Mngcrrcnt Dist Hot? BOILER-COMP OtN OR 100.000
vBTBTU) R=
Yea No
havoread the hav o materials Sections
2menv5533 and 25534.
of BOILER.COMP(OVER 100,000 BTU)
the GBandthainane bSafetyCode, Socia 75505,ve a Land,that ]
understand that notify
the occupant
of the equiyments which
that itIsmy NEW RESIDENTIAL MECIi. �.IT IW Ty bI 13ef'
responsibility tois to notify the occupant of the requUcnenta which must be met
prior to issuance ofaCertificate oflhcupanry. �
TOTAL: ISSUED
Owner or authoricd agent Date ISSUED BY:C\\,'�'�'a'V
OFFICE COPY